Journal Club- Ultrasound Guided Nerve Blocks for Headaches and Facial Pain

The PMRExam Podcast

Exploring the Role of Ultrasound in Headache Evaluation and Treatment

A Journal Club based on Dr. Andrea Trescott's article:

Ultrasound for evaluation and treatment of headaches. Anaesth Pain & Intensive Care 2017;21(2):241-253.

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David Rosenblum, MD

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In this Podcast, Dr. Rosenblum discusses patient's in his practice who responsed to ultrasound guided nerve blocks in the treatment of headaches. He discusses the use of ultrasound injections as opposed to medication to manage the pain and references Dr. Trescott's comprehensive article on the various nerves and clinical presentations of headaches related to terminal nerve entrapment or irritation.

Dr. Rosenblum discusses

• Supraorbital Neuralgia
• Auriculotemproal Nerve
• Anatomy
• Clinical presentation
• Interventional Pain Therapies

Summary of Dr. Trescott's Article and Key Points:

• Headaches, affecting 28 million people in the US, pose a significant burden on society in terms of medical costs and lost labor. They are complex neurologic disorders with diverse origins and causes.
• Headaches are often viewed as the primary pathology, but they are fundamentally a symptom. Understanding them is an evolving science, and their patterns can be recognized for effective diagnosis and treatment.
• In 2003, Pareja et al proposed the term "epicrania" for headaches triggered by extracranial causes, suggesting a link between intracranial components and extracranial nerves.

Peripheral Triggers and Plastic Surgery:

• Plastic surgeons noted relief of migraines through corrugator muscle resection and botulinum toxin injection, indicating peripheral headache triggers.
• Severe migraines post-head or neck injury may have an extracranial origin, suggesting peripheral nerve irritation. Traditional migraine medications may offer modest relief.
• Primary treatment involves inhibiting nerve irritation through interventional pain techniques, turning off the pain origin and associated migraine centers.

Ultrasound Advantages:

• Evaluation and injection of nerves have traditionally used landmarks and fluoroscopic images, but ultrasound offers unique advantages.
• Nerves often travel with arteries, potentially contributing to "throbbing" pain. Ultrasound provides a more precise and dynamic visualization of these structures.

Exploring Extracranial Causes:

• The International Classification of Headache Disorders (ICHD) categorizes headaches as primary or secondary. While valuable, it broadly defines peripheral nerve contributions as "Other Terminal Branch Neuralgias."
• The study of extracranial peripheral nerve entrapments and dysfunction reveals overlap between ICHD-defined headaches and potential nerve entrapments causing these pain patterns.
• Collaboration with disciplines like pain management enriches the understanding and treatment options for headaches.

Conclusion:

• Headaches, often seen as isolated intracranial phenomena, may have extracranial triggers. Understanding and treating these triggers, especially through ultrasound-guided techniques, present a promising avenue in headache management.

NRAP Academy also offers:

• Board Review
• Anesthesiology
• Pain Management
• Physical Medicine and Rehabilitation
• Regenerative Medicine Training
• Live Workshops
• Online Training
• The Virtual Pain Fellowship (online training program with discount to live workshops)

Private Ultrasound Training Available

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Reference:

• Trescot A. Ultrasound for evaluation and treatment of headaches. Anaesth Pain & Intensive Care 2017;21(2):241-253.

Publication Details:

• Received: 15 Aug 2015, Reviewed: 2 Jun 2016, Accepted: 28 Jun 2016.

This podcast explores the dynamic relationship between intracranial and extracranial factors in headaches, shedding light on potential breakthroughs in their evaluation and treatment.

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